Project Origin and Development
2016
Pilot Study
The pilot project, conducted by experienced nurses and social workers, 249 elderly persons living alone were invited to complete a comprehensive health assessment at District Elderly Community Centers (DECC), but only 92 participants completed the assessment. It was found that some of the most common reasons for the elderly to not participate in the study were immobility, cognitive impairment, and unable to spare 2 hours to attend the center. This pilot study allowed our project team to recognize that providing center-based services for the frail elderly is extremely challenging. As a result, adjustments were made during phase I of the project.
2017/18
Phase I
Based on the findings in the pilot project, the mode of healthcare delivery was adjusted from center-based services to home-visit services. Health assessments were conducted during home visits.
2055 elderly were invited to participate in the project, and 1652 elderly had completed the Comprehensive Geriatric Assessment (CGS) during the one-year project period. Each elderly was assessed by a nurse and a social worker. Consultation and referral services were also provided.
After adjusting from center-based services to home-visit services, the assessment completion rate increased significantly from 37% to 80.4%. The service team successfully referred 29 elderly cases suffering from woodlouse infestation, and helped 145 elderly persons seek medical assistance to cope with their health issues. Also, 11 elderly had medical emergencies during the home visit and were sent to hospital for treatment, which included cases such as hypotension, hypertension, hyperglycemia, and shortness of breath. In addition, the service team provided medication guidance for 127 elderly. Furthermore, 12 elderly had emotional distress and suicidal thoughts during the assessment, and our service team immediately offered emotional support and referred the elderly to a social worker of a partnering organization for counseling services.
In terms of health data, the project team found that among the elderly who did not have a medical history of hypertension, 40.1% of the elderly were considered at risk for undiagnosed hypertension. Among the elderly who did not have a medical history of diabetes, 22.3% of the elderly were considered at risk of undiagnosed diabetes. In addition, among the elderly who had been diagnosed with hypertension or diabetes, 45% of the elderly had uncontrolled blood pressure, and 59% of the elderly had uncontrolled diabetes despite treatment with medications. These results suggest more effective methods and strategies need to be developed in order to improve the health and wellbeing for the elderly.
2018-2020
Phase II
During the first phase of the study, the project team realized that the existing community and medical resources are scarce and may not be able to effectively support the various health needs of the elderly, especially when it comes to medication guidance and building healthful lifestyle habits (such as dietary and physical activity habits). For this reason, the project entered its second phase. During this phase, Health coaching, a patient-centered approach to delivering care that has been proved useful in chronic disease management in primary care and community settings, was used as the major intervention approach in providing personalized chronic disease management services. Our project team, composed of professional nurses and social workers, provided comprehensive and appropriate health services for the elderly, with the aim of improving their quality of life and meeting the desire of many elderly people, which is to "age in place".
2020-Now
Phase III
We hope to use our past experiences and knowledge to continue to provide the elderly with personalized care and disease prevention services, with the long-term goal of helping the elderly "age in place". Our service delivery approach is based on the world-renowned innovative community nursing model - "Buurtzorg: the Dutch model of neighbourhood care", which places emphasis on individualized, community-based care, and medical-social collaboration. For details, please refer to "Our Services" on this page.
Taking the vital signs for the elderly at a District Elderly Community Center
Providing guidance and sharing knowledge regarding blood sugar
Taking an elderly, who had not gone out for a long time, for a walk.
Partnering with an elderly to create a daily checklist designed to improve their health
Assessing health needs of an elderly outside of his home
Performing a hand injury assessment for an elderly.